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More EPAP, IPAP or Pressure Support?
#1
Hello all.

I feel that I am closing in on my optimum pressures but have stumbled upon a new puzzle and don't know which adjustment might be correct.

My AHI's are almost always under 3, 30 day average is 1.88, but some days I wake up feeling rested and some days I don't. I suspect because of RERA's.

Over the last few months I have slowly raised my EPAP, IPAP and PS to my current settings of EPAP 8.5, IPAP 15, PS 2-6.

My avg's for last week were EPAP avg was 8.52 and max was 9.5. Avg IPAP was 11.88 max of 15 and 90% 14.7.

I am primarily a back sleeper because of other issues that prevent me from sleeping on either side for extended periods of time.

My partner has been noticing a light snoring sound on inhalation sometimes resolved with an arousal, sometimes it continues. I know this is happening when I first fall asleep, what I don't know is if it continues all night.

I am not sure about is if my airway is partially collapsed because my EPAP is too low or if my IPAP is too low or are both reasonable and I just need to increase my pressure support. Is my pressure too low when I first fall asleep while waiting for my machine to increase PS?

I have continued to raise my EPAP pressure as I have raised my IPAP pressure even though my EPAP pressures are normally near my minimum pressure. Should I not continue to raise EPAP?

The majority of my events are Flow restrictions, RERA's and Hypopneas.

I am happy to provide any additional sleepy head data, not sure what would be most helpful.

Thanks to all who take the time to read and offer suggestions.
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#2
If most 'events' are hypopneas, then the first thing to do is change the range of PS to 4-6 from 2-6.

In general, you raise EPAP for Obstructive events and also for snoring events.
You raise PS to take care of residual hypopneas after obstructives have been dealt by the EPAP.

For more detailed analysis, please post your sleepyhead summary data and waveform + events+ other graphs screenshot for a characteristic night.
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#3
Assuming that you are not getting significant centrals, I would raise my EPAP to just under my median.
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#4
Is this is what you were looking for?

    [attachment=1870][attachment=1869]
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#5
I am going to make a liar out of myself. If it were me I would raise the PS to 4-6 like ashsf said and also raise the EPAP and IPAP each up 0.5 or 1.0 cm/H2O. That is just me and I tend to probably change more things at one time than may be advisable so you might want to change these one at a time and I would start with the EPAP.

Best Regards,

PaytonA
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#6
(11-13-2015, 06:16 PM)Cookie Wrote: Over the last few months I have slowly raised my EPAP, IPAP and PS to my current settings of EPAP 8.5, IPAP 15, PS 2-6.

My avg's for last week were EPAP avg was 8.52 and max was 9.5. Avg IPAP was 11.88 max of 15 and 90% 14.7.

Your max IPAP setting is 15, yet you're above 14.7 for 10% of the time. This indicates to me that you're hitting the max of 15 for significant periods of time. I would raise that Max IPAP to 16 unless there's some compelling reason not to.

Look at your pressure graph in SH. It's running up against the ceiling. I have mine set to 13.6 and it rarely reaches 13.

I think you also need to raise the minimum PS. Why would you let it go as low as 2?
Sleepster
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#7
Looking at your charts, you can see that your minimum EPAP can't take care of all obstructive events. To take care of those, raise your min EPAP by 0.5cm as PaytonA suggested. And raise PS range to 4-6cm.

Run this for 7 nights and then evaluate. Please update this thread with new charts.
Started APAP 4-20, Closed range to 7.5-14, then straight 8.0 w/ Aflex 3
RDI always below 1. But sleep much much better at straight pressure.
Started on F10, Tried Quattro Air successfully. Finally settled on P10.
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#8
You're pretty close to my settings. I use a minimum PS of 4.0 and that resolved the RERA. I allow IPAP to go to 19, but it almost never exceeds 16, so the auto function will work if you let it.

I agree with some of the early posts. EPAP 8.5 PS 4-6 IPAP 18. Let the machine go where it will within that range.
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#9
Thanks all!

I don't always adjust quickly to changes even when they are small so I waited until Saturday night to make any changes as Saturday is a work day for me.

A brief history to fill in some of the questions.

I have been a long time user of CPAP / BIPAP. I thought it was time for a new sleep study / doctor as I wasn't feeling that my therapy was still working well. I have lost a significant amount of weight and I questioned if my settings were still correct.

My sleep study titration changed me from BIPAP (5-11 ps 0-3) back to CPAP at 12. With this came significant issues with mask leaks and little to no sleep. I changed DME and they worked with me to find a FFM that didn't leak and with much complaining my doctor reduced my pressure to 10. When I questioned why I had been changed back to CPAP I was told that it was data driven and that was it.....

I gave it a month and since I still wasn't sleeping well, wasn't feeling rested and it didn't appear that the doctor was interested in any of this since my AHI is well below the magic 5, I decided that with the help of folks here that I was going to take the controls into my own hands. I didn't think I could make it much worse.

As a starting point I went back to my original BIPAP settings and have been SLOWLY adjusting everything UP from there while reading and trying to understand which setting is the right one to change for which issue.

Last night I increased my PS to 4-6 as recommended. I did not make any changes to EPAP or IPAP as I want to make slow changes to determine if they are correct or not and if not I know what to change back. I had difficulty falling asleep and even though my mask was on I did not fall asleep until about 1 am.

Here is the chart from last night




Attached Files Thumbnail(s)
   
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#10
Two week update.

I have made two changes since my last post and it seems like I still need to tweak my settings up slightly more as I am still having obstructive events.

I first moved my EPAP to 9.5 IPAP to 17 pressure support to 4 - 7.5. I felt the changes were a positive move as I felt more rested and found it easier to remain focused thru the day.

Since I was still seeing obstructive events I made a second change to EPAP 10 IPAP 18 and pressure support to 4-8.

My averages for last week were EPAP 10.13 Average IPAP 15.55 90% IPAP 18.

Since I am still having obstructive events am i correct that I need to still increase my EPAP?

Since I hit my maximum IPAP every night am I correct that I also need to raise my IPAP and pressure support?

This attached screenshot is from last night.    

Thanks to all for the advice and opinions.

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